Non-Clinical Healthcare Consulting Job at EY | MBBS/MD Professionals Apply!

About the Company

EY (Ernst & Young) is one of the world’s leading professional services firms, providing assurance, consulting, tax, strategy, and transaction services to clients across the globe. Operating in more than 150 countries, EY helps governments, businesses, and organizations solve complex challenges through innovation, digital transformation, and strategic consulting. Its Government & Public Sector (GPS) practice works closely with public sector organizations to improve healthcare, governance, and public services. EY is recognized for its commitment to professional development, inclusive work culture, and career growth opportunities.

Role Overview

This role involves reviewing and auditing healthcare claims processed under government health schemes. The selected candidate will assess medical necessity, appropriateness, admissibility, and compliance with scheme guidelines. The position offers exposure to government healthcare programs and healthcare policy implementation within the Government & Public Sector (GPS) practice, with work focused on healthcare claims adjudication, medical audits, and quality improvement initiatives.

Key Responsibilities

• Review healthcare claims processed by Claims Processing Doctors and adjudicators.
• Assess medical necessity, admissibility, and appropriateness as per scheme guidelines.
• Conduct medical and technical audits, including random and death audits.
• Identify discrepancies, incorrect adjudication decisions, and SOP deviations.
• Prepare detailed audit findings, observations, and follow-up reports.
• Deliver technical training and develop training materials and SOPs.
• Monitor adjudication quality and recommend workflow improvements.
• Identify suspicious claims and coordinate with fraud-control and analytics teams.

Qualifications

Essential: MBBS degree from a recognized university or institution.

Desirable: MD or an equivalent postgraduate medical qualification.

Experience: Minimum 3 years and less than 6 years of post-qualification experience in healthcare or medical insurance-related domains.

Skills Required

• Strong understanding of healthcare claims adjudication and medical audit.
• Knowledge of health insurance processes and claims management.
• Ability to interpret clinical records and assess medical necessity.
• Understanding of treatment guidelines and benefit packages.
• Knowledge of quality assurance and audit methodologies.
• Familiarity with fraud detection and risk identification.
• Strong analytical, report writing, and presentation skills.
• Effective communication and stakeholder management skills.